Overview
This Performance Task Assessment is based on a case study set in Brooklyn Presbyterian Hospital, in the Park Slope neighborhood of Brooklyn, New York, as the hospital confronts the new quality standards set by the Patient Protection and Affordable Care Act (PPACA) for Medicare patients. To complete this Assessment, read the scenario below, and then complete Parts I and II that follow. You will use information from the scenario, along with the supporting documents, to demonstrate your ability to adapt internal policies and practices to align with changes to healthcare laws and regulations.
Part 1: Analyzing HRRP Policy and Evaluating Hospital Performance
Read the Health Affairs Policy Brief on the “Medicare Hospital Readmissions Reduction Program.” Then, analyze the document “Brooklyn Presbyterian Hospital—Unplanned Readmission Rates,” which presents statistics on the unplanned readmission rates at the hospital and how they compare to the national averages. Also, review the current, “Acute Inpatient Hospital Admissions Payment Policy” document.
Use these resources to develop a report (4–5 pages) to the CEO that completes the following:
- Describe the key elements of the Medicare Hospital Readmissions Reduction Program (HRRP) established in the Affordable Care Act (ACA).
- Identify two factors at Brooklyn Presbyterian Hospital based on the current policy that contribute to the risk of failing to meet HRRP criteria.
- Explain how current internal practices and the changes in policy might positively impact alignment to current and future healthcare laws.
- Suggest one revision to the current policy to help Brooklyn Presbyterian Hospital meet HRRP criteria.
- Suggest one change in current practice across the hospital’s organization in order to help Brooklyn Presbyterian Hospital meet changes in Medicare reimbursement. Include 2–3 sentences explaining the importance of adapting internal policies and practices to align with changes in healthcare laws and regulations.
- Describe at least three key elements needed in a new program to earn the maximum reimbursement under HRRP by reducing readmission rates.
- Create five goals for Brooklyn Presbyterian Hospital for earning the maximum reimbursement by following the HRRP criteria. These goals may focus on processes or outcomes.
Part 2: Developing an Action Plan to Maximize Reimbursements and Adapt to Change
Political pressure will result in changes to Centers for Medicare and Medicaid Services (CMS) policy and reimbursements. Develop a 10- to 12-slide presentation, to senior management, proposing strategies for executing a plan for earning maximum reimbursement under HRRP, specifically by changing the behavior of providers and patients. Your goal is to secure resources to put your plan into action. In this presentation, explain your approach, your plan for implementation, at least two ways you will prepare and monitor for change in CMS policy, and your education plan for staff.
Brooklyn Presbyterian Hospital Acute Inpatient Hospital Admissions Payment Policy
Please Note: The policy described below is hypothetical.
Purpose of the Billing Process
The purpose of the hospital billing process is to obtain reimbursement for services and items rendered by the hospital. Reimbursement is received from patients, insurance carriers, and government programs. The hospital billing process begins when a patient arrives at the hospital for diagnosis and treatment of an injury, illness, disease, or condition. The patient’s demographic and insurance information is obtained and registered in the hospital’s information system. Physician’s orders or a requisition outlines the patient care services required. Patient care services and items provided during the patient’s stay are recorded on the patient’s account. Charges are posted to the patient’s account by various departments. When the patient leaves the hospital, all information and charges are prepared for billing.
Definition
An acute inpatient hospital is a facility licensed as a hospital by the State Department of Public Health. This type of facility makes diagnosis and treatment available and offers provider services 24 hours a day but does not include any facility licensed as a chronic disease and rehabilitation hospital; any hospital licensed primarily to provide mental health services; or any unit of a facility licensed as a nursing facility, chronic disease unit, or rehabilitation unit.
An inpatient admission is a member’s admission to a hospital for the purpose of receiving inpatient services.
Authorization Requirements
The rate of payment is determined by the effective date of a member’s inpatient admission and applies for the length of the admission (i.e., any rate change under the contract during the member’s stay will not apply). We require notification for emergency inpatient admissions.
We require prior authorization 5 business days prior to an elective admission.
We require notification through an emergency services provider for all behavioral health inpatient admissions.
Billing and Reimbursement
Providers must file a claim for hospital inpatient services through an 837i HIPAA-compliant file or on a 1234A form, using industry standard revenue codes.
An inpatient reimbursement rate is the rate in effect on the date a member begins an inpatient admission. The inpatient reimbursement rate includes all services a member receives during an inpatient admission, as applicable (see our Hospital Hierarchy Payment Policy). We will only reimburse for the portion of a patient’s stay during which they were enrolled as a Health Plan—Network Health member.
Hospital Newborn Services
We reimburse for inpatient services for well newborns. With prior authorization, we reimburse for inpatient services for boarder babies and newborns admitted to a neonatal intensive-care unit (see our Hospital Newborn Services Payment Policy).
Provider Preventable Conditions and Serious Reportable Events
We do not reimburse for provider preventable conditions or serious reportable events (see our Provider Preventable Conditions and Serious Reportable Events Payment Policy).
Adapted from:
Tufts Health Public Plans. (2015). Acute inpatient hospital admissions payment policy. Retrieved from
https://network-health.org/Providers/Policies-and-Manuals/Payment-Policies/Acute-Inpatient-Hospital-Admissions-Payment-Policy.aspx
©2015 Walden University
1
Brooklyn Presbyterian Hospital (BPH)
Hospital
re-‐admission
rates
through
6/30/2012
Description
of
measures
below:
Measures
of
30-‐day
death
(mortality)
show
when
patients
die,
for
any
reason,
within
30
days
of
admission
to
a
hospital.
BPH U.S.
NATIONAL
RATE
Rate
of
unplanned
readmission
for
heart
attack
patients No
Different
than
U.S.
National
Rate 18.30%
Death
rate
for
heart
attack
patients No
Different
than
U.S.
National
Rate 15.20%
Rate
of
unplanned
readmission
for
heart
failure
patients Worse
than
U.S.
National
Rate 23.00%
Death
rate
for
heart
failure
patients No
Different
than
U.S.
National
Rate 11.70%
Rate
of
unplanned
readmission
for
pneumonia
patients Worse
than
U.S.
National
Rate 17.60%
Death
rate
for
pneumonia
patients No
Different
than
U.S.
National
Rate 11.90%
Rate
of
unplanned
readmission
after
hip/knee
surgery No
Different
than
U.S.
National
Rate 5.40%
Rate
of
unplanned
readmission
after
discharge
from
hospital
(hospital-‐wide) Worse
than
U.S.
National
Rate 16.00%
Below,
each
hospital’s
performance
on
the
death
(mortality)
and
unplanned
readmission
measures
is
compared
to
the
U.S.
national
observed
rates
for
those
measures.
The
performance
results
take
into
account
how
sick
patients
were
before
they
were
admitted
to
the
hospital.
Measures
of
30-‐day
unplanned
readmission
show
when
patients
who
have
had
a
recent
hospital
stay
need
to
go
back
into
a
hospital
again
for
unplanned
care
within
30
days
of
their
initial
discharge.
Patients
who
are
admitted
to
the
hospital
for
treatment
of
medical
problems
sometimes
get
other
serious
injuries,
complications,
or
conditions,
and
may
even
die.
Some
patients
may
experience
problems
soon
after
they
are
discharged
and
need
to
be
admitted
to
the
hospital
again.
These
events
can
often
be
prevented
if
hospitals
follow
best
practices
for
treating
patients.
Readmissions,
Complications
and
Deaths: